Pressure control for burns recovery

TWO sewing machines rest side-by-side, their threaded needles poised in mid-air and ready for action. A neat rack of beige lycra rolls are at one end of the room while a whiteboard scribbled with deadlines is fixed on the opposite wall. Two seamstresses take centre stage. Bent over a green workbench, they diligently cut patterns from cloth bits, snipping sounds filling the otherwise silent room.

Welcome to the sewing unit at Singapore General Hospital’s Block 1 Rehab Centre, a modest but important place where pressure garments are made. Part of the Occupational Therapy Department, it falls under the Burns and Plastic Rehabilitation specialty and primarily serves patients of the SGH Burns Centre. Pressure treatment. During burns recovery, the skin may proliferate out of control to form rigid bumps called hypertrophic scars. To limit the formation of hypertrophic scars – which can hinder mobility when they grow over body joints – garments that exert pressure are worn, said Ms Anna Tan, Head of Occupational Therapy and Chief of Burns and Plastic Therapy Services at SGH. Generally, patients wear them for at least 23 hours daily over two years. “Each pressure garment is customized to the patient’s needs and the measurements go into his or her medical files,” said Ms Tan. “This is part of the medical treatment, although not the conventional type. When the scar stops growing, they will be flatter and softer from the pressure effect.”

Making a pressure garment come in various forms such as masks, gloves, arm tubes, pants and jackets. To make a pressure garment, measurements taken by the occupational therapist are given to the seamstress who calculates the reduction in garment size necessary for the pressure effect. The design of the garment is shaped primarily based on how the patient is burnt, but other considerations are also important. For instance, “we need to know if the patient will get help from family members in wearing the garments,” said Ms Tan. Comfort for the patient is important. To avoid irritating the skin, garments are made inside out with the seams on the outside, which also allows for easy grip and wearing. Velcro zips and elastic bands are added to keep the garments secure. For the severely burnt, garment designs require creativity like using double layers for better pressure, or pockets sewn for sturdy inserts like foam and putty-like elastomer at desired spots. The material used needs to give a snug fit without restricting movement, be able to stretch four ways instead of two for conventional fabrics and ‘breathe’ for comfort.

The SGH Burns Centre is the only burns centre in Singapore and it also serves the region. As such, we need to find a fabric in a colour that suits the majority,” said Ms Tan. “Not everyone will be happy with the colour but we have to find one which won’t look like a white patch on Indians or too dark on Caucasians.”Patients return monthly to check if their garments have loosened with daily wear, or became too tight because of weight gain. Generally, a pair of garments, used alternately, lasts about three months before brand new ones are needed.

Skin donation still a tough sell

Only 2 donors last year; most mistakenly believe it means disfigurement

PEOPLE shy away from the thought of donating the skin of a loved one who has died. Consequently, there were only two donors to the National Skin Bank last year.
One was a three-month-old boy, Ryan Wong, who died from complications following surgery for a cleft lip.His parents, Mr Norman Wong, 47, and his wife Juliet, 38, donated his skin, as his other organs were too small to be viable. The identity of the other donor last year is unknown.

There is one donor so far this year: Triad leader Tan Chor Jin, 41, better known as 'One-eyed Dragon', who was hanged in January. He had asked for his skin, cornea and kidneys to be given away.

The shortage in skin donations is a long-standing issue, said Associate Professor Colin Song, director of Singapore's biggest burns unit, at the Singapore General Hospital (SGH).
A sizeable bank is needed to cope with accidents such as the one which occurred on Feb 27, when five workers suffered chemical burns from an acid spill at Chemic Industries in Tuas. Four have died.

Skin, the largest organ in the human body, is not covered under the 22-year-old Human Organ Transplant Act, so hospital staff have to ask the deceased's family to consent to a donation.
The answer is often 'no', primarily because people mistakenly believe donating a dead person's skin means disfigurement.

Prof Song, who also heads the department of plastic, reconstructive and aesthetic surgery at the hospital, said it was not the case. Only the outermost layer between 0.25mm and 0.4mm thick - thinner than a piece of facial tissue paper - is taken from flat surfaces like the thighs and back. These are concealed by clothing and will not mar the donor's appearance.
Up to 2,000 sq cm of skin - about the size of a page of this newspaper - can be harvested from those areas in an adult.
To be prepared for a crisis, such as a national fire disaster, the SGH Skin Bank needs 60,000 sq cm of skin - or skin from 30 adult donors. It has that amount now, but Prof Song said it could do with more such donations.

Singapore has had to import skin from Australia, the United States and the Netherlands, at $200 for a piece about the size of an adult's palm. In 2007, only one donation was made and, between 2004 and 2006, no more than two to four each year.
Prof Song explained that donations are rare also because people do not know how useful donated skin is. It is used as a temporary dressing in cases of severe burns of 40 per cent of the body and higher, to reduce the growth of bacteria and loss of the patient's vital fluids. It is usually discarded in three weeks. By then, new skin which has been cultivated from the patient's own cells would have grown enough to be used as a replacement.
Burn victims with less than 40 per cent burns can use their own skin for grafts, usually harvested from the thighs.

An example was Yio Chu Kang MP Seng Han Thong, who suffered about 15 per cent burns to his face, arms and chest. He had a graft using skin from his inner thighs.
To create public awareness, the SGH Burns Centre and the Burns Support Group are organising a public forum later this year to discuss skin donation.
And since 2006, the SGH Skin Bank, together with the National Organ Transplant Unit, has gone to junior colleges and polytechnics to tell students about the importance of organ and tissue donation.

The SGH Burns Centre treats about 300 burn patients a year. About 15 per cent of them have major burns, with between 30 and 40 per cent of the surface of their body burnt.

By Judith tan

Calls for skin donation to be included under HOTA

Doctors hope the Human Organ Transplant Act (HOTA) will include skin donation on its list, as Singapore faces a severe shortage in its bank. And it has had to get help from countries like the US and Australia. The call for more skin donations was emphasized at a forum on Management of Burns held at the National Library on Saturday. It was oganised by the Burns Support Group and the Singapore General Hospital (SGH) Burns Centre. Some six months ago, 3rd Sergeant Karthigayan Ramakrishnan was wheeled into SGH for burns treatment following a Taiwan fighter jet crash incident. After spending eight weeks in hospital, the 24-year-old burns survivor is now out and about. Karthigayan has gone through multiple operations and skin grafts, but he still has two more minor surgeries ahead of him. Karthigayan and other burns survivors, through their experience, are more convinced than ever of the critical need for skin donation here in Singapore. "Donor skin is very important because as soon as they cover you up (with the donated skin), it helps in the treatment and the healing process. To be very frank, I was very ignorant about it, and I never realised that it could happen to me," said Karthigayan. "We've got to create the kind of awareness; it's something that can happen to anybody... not just military men or firemen," he added.

Another recovering survivor, 26-year-old Chia Hiang Yong, was burnt after his motorbike caught fire two months ago. "The number of skin we get over the past year is amazingly little, compared with other transplants like heart transplants and all that. I think skin should also be part of the HOTA as well," said Chia.



At the forum, experts gave an update on the skin bank. "Over a 10-year period since 1998, we've had about 97 of the severe burn victims benefiting from about 320,000 square centimeters of donated skin, roughly half the size of a badminton court. 49 Singaporeans who have departed and passed on donated just over 100,000 square centimeters of skin. So we had a shortfall of about 220,000 square centimeters," said Dr Colin Song, Senior Consultant & Head of Singapore General Hospital Burns Centre. He said Singaporeans' donations to the skin bank only met a third of the burn victims' needs. Going forward, he said other countries like Australia are also running low in its skin bank, making it more crucial for Singapore to beef up its own supply.

November 2007
By May wong

This is how our BSG began

Burns unit at SGH starts support group to help patients

Singapore General Hospital has for the first time set up a support group for burns victims.The specialized burns unit at the hospital - which treats patients from all over the region - hopes the new group will speed patients' recovery.

The SQ006 crash in Taipei and the Jakarta Marriott bomb blast were both tragic events for victims who died and for those who survived but were burnt. Three years on, SAF Major Ang Ming Chuan, an SQ006 survivor, lives to tell the story of how he coped.

He and another burns patient, Freddy Neo, saw the critical need for a support group while they were in hospital, recovering together. Mr Neo said: "When we were injured we find that recovering from burns took a long time and there is no medicine that can help a burns patient except he himself that needs to go through therapy and exercises and putting on pressure garment diligently to suppress the scars."

That was what Carol Chia, who was at the Jakarta Marriott coffeehouse the day of the blast, is going through right now. She recalls the agony on the faces of her family, when they saw her in hospital. Carol said: "I have always felt that the emotional and spiritual part is 80 percent, 20 percent is a physical burn."

Such a support group recognizes that healing goes way beyond just the physical as there is the emotional trauma as well. Burns survivors in the group have been able to draw strength from those who have gone before them.

Badron Nishah Abdul Ghani, Burns survivor, said: "There are physiotherapists, psychologists, there're occupational therapists, these people are there to help you but you feel they don't understand because they haven't gone through it themselves." The support group organizes home visits, seminars and workshops to help people like Nishah, who suffered 60 percent burns from a kitchen explosion while she was in the US.